Development and Psychopathology 29 (2017), 651–673 # Cambridge University Press 2017 doi:10.1017/S0954579417000244 Circle of Security–Parenting: A randomized controlled trial in Head Start JUDE CASSIDY,a BONNIE E. BRETT,a JACQUELYN T. GROSS,a JESSICA A. STERN,a DAVID R. MARTIN,a a b JONATHAN J. MOHR, AND SUSAN S. WOODHOUSE aUniversity of Maryland at College Park; and bLehigh University Abstract Although evidence shows that attachment insecurity and disorganization increase risk for the development of psychopathology (Fearon, Bakermans- Kranenburg, van IJzendoorn, Lapsley, & Roisman, 2010; Groh, Roisman, van IJzendoorn, Bakermans-Kranenburg, & Fearon, 2012), implementation challenges have precluded dissemination of attachment interventions on the broad scale at which they are needed. The Circle of Security–Parenting Intervention (COS-P; Cooper, Hoffman, & Powell, 2009), designed with broad implementation in mind, addresses this gap by training community service providers to use a manualized, video-based program to help caregivers provide a secure base and a safe haven for their children. The present study is a randomized controlled trial of COS-P in a low-income sample of Head Start enrolled children and their mothers. Mothers (N 141; 75 intervention, 66 waitlist control) completed a ¼ baseline assessment and returned with their children after the 10-week intervention for the outcome assessment, which included the Strange Situation. Intent to treat analyses revealed a main effect for maternal response to child distress, with mothers assigned to COS-P reporting fewer unsupportive (but not more supportive) responses to distress than control group mothers, and a main effect for one dimension of child executive functioning (inhibitory control but not cognitive flexibility when maternal age and marital status were controlled), with intervention group children showing greater control. There were, however, no main effects of intervention for child attachment or behavior problems. Exploratory follow-up analyses suggested intervention effects were moderated by maternal attachment style or depressive symptoms, with moderated intervention effects emerging for child attachment security and disorganization, but not avoidance; for inhibitory control but not cognitive flexibility; and for child internalizing but not externalizing behavior problems. This initial randomized controlled trial of the efficacy of COS-P sets the stage for further exploration of “what works for whom” in attachment intervention. Childhood experiences of parental insensitivity, as well as in- some children (e.g., those from low-income households, secure and disorganized attachment, are precursors of a vari- with depressed mothers, or with exposure to violence/trauma) ety of problematic developmental outcomes; for some are at increased risk for insecure and disorganized attachment outcomes (e.g., physiological dysregulation, externalizing (e.g., Bakermans-Kranenburg, van IJzendoorn, & Kroonen- problems, and other forms of developmental psychopathol- berg, 2004; Fearon & Belsky, 2016; Lyons-Ruth & Jacobvitz, ogy), disorganized attachment brings heightened risk even 2016) has led to heightened interest in the development and in comparison to other types of insecure attachment (e.g., evaluation of interventions targeting infants and young chil- Bernard & Dozier, 2010; Oosterman, De Schipper, Fisher, dren with these risk factors. The past 20 years have witnessed Dozier, & Schuengel, 2010; for reviews, see Fearon, Baker- the development of numerous therapeutic programs to pre- mans-Kranenburg, van IJzendoorn, Lapsley, & Roisman, vent or ameliorate early insecure and disorganized attach- 2010; Groh, Roisman, van IJzendoorn, Bakermans-Kranen- ments, often targeting maternal sensitivity as a means of burg, & Fearon, 2012; Thompson, 2016). Evidence that influencing child attachment (e.g., Bernard et al., 2012; Cic- The Zanvyl and Isabelle Krieger Fund provided support to Jude Cassidy to conduct this study. Additional support for manuscript preparation was pro- enting groups; Susan Paris and Bonnie Conley assisted with Strange Situation vided by Janet W. Johnson Fellowships (to J.T.G. and D.M.), the National coding; Audrey Bigham and Ben Mitchell supervised the executive function- Science Foundation Graduate Research Fellowship Program Fellowship (to ing coding teams and managed the executive functioning data; Samiha Islam J.A.S.), and Grant R01 HD068594 from the National Institute of Child compiled the reference list; and many hardworking and dedicated undergrad- Health and Human Development (to S.S.W.). We are grateful for the help uate research assistants assisted with data collection and coding. We also of the following people: Betsy Krieger, Karen Kreisberg, Linda Heisner, thank the directors and staff of the participating Head Start centers: Dayspring and Brooke Hisle provided important leadership and coordination; Glen Programs, Emily Price Jones Head Start/Y of Central Maryland, and Catholic Cooper, Kent Hoffman, and Bert Powell developed the Circle of Security– Charities Head Start of Baltimore City. Above all, we are grateful to the fam- Parenting intervention and served as intervention supervisors; Anna Ditkoff- ilies who generously participated in our study. Dorsey, Tara Doaty, Pam Hoehler, and Barbara Johnson served as interveners; Address correspondence and reprint requests to: Jude Cassidy, Depart- Danielle Gregg and Elizabeth Thompson provided and coordinated labora- ment of Psychology, 2147C Biology/Psychology Building, University of tory space at the Family Center at Kennedy Krieger Institute in Baltimore, Maryland, 4094 Campus Drive, College Park, MD 20742; E-mail: jcassidy@ Maryland; Erika Johnson conducted waitlist control Circle of Security–Par- umd.edu. 651 /AA47879CAD,45C7:8AC:AC838CDA914C47 38CD05C4C8DA-C4,,D58A8.45C7:8.AC88CDA9D8444584 D,45C7:8AC:AC88CDD,7AAC:2 652 J. Cassidy et al. chetti, Rogosch, & Toth, 2006; Juffer, Bakermans-Kranen- it is to be implemented and the diverse at-risk families it is in- burg, & van IJzendoorn, 2008; Lieberman & Van Horn, tended to serve (e.g., Head Start programs; Cooper et al., 2009; 2005, 2008; Sadler et al., 2013; for reviews, see Berlin, Zea- Woodhouse, Powell, Cooper, Hoffman, & Cassidy, in press). nah, & Lieberman, 2016; and Steele & Steele, in press). Some interventions have succeeded in increasing maternal sensitiv- Theoretical foundations of COS-P: Secure base provision, ity (e.g., van Zeijl et al., 2006), some in reducing the rate of with a focus on caregiver response to child distress insecure and/or disorganized attachment (e.g., Cicchetti et al., 2006; Lyons-Ruth, Connell, Grunebaum, & Botein, A central theoretical foundation of COS-P is Bowlby’s 1990), and some both (e.g., Heinicke, Fineman, Ponce, & (1988) assertion, at the heart of the attachment framework, Guthrie, 2001; for reviews, see Bakermans-Kranenburg, that children are most likely to develop a secure attachment van IJzendoorn, & Juffer, 2003, 2005). when they have confidence in an attachment figure to With few exceptions (e.g., Juffer et al., 2008), these inter- whom they can return as a safe haven for comfort when dis- ventions are expensive and thus not practical for large-scale tressed, and then use as a secure base from which to confi- public health implementation. For example, high levels of inter- dently explore. The COS-P focus on caregiver secure base vener skills, accompanied by extensive protocol training and provision leads to an intervention emphasis on sensitive re- supervision, are often required to create and deliver individual sponsiveness to child distress (as opposed to sensitivity in diagnostic and treatment plans (Sadler et al., 2013). Several in- nondistress contexts). Sensitive responding to child distress terventions rely on individualized video-feedback techniques not only fosters the child’s use of the caregiver as a safe haven (in which interveners select videotaped parent–child interac- (because of expectations of comfort) but also fosters use of tions to review with the parent; e.g., Bernard & Dozier, 2010; the caregiver as a secure base for exploration (because a dis- Egeland & Erickson, 2004). Although meta-analysis has dem- tressed child cannot explore). In essence, a child’s experi- onstrated video-based feedback is valuable in promoting effec- ences of coregulating distress with a responsive caregiver tive parenting (Bakermans-Kranenburg et al., 2003), it involves shape adaptive psychobiological responses to stress (includ- the added expense and logistics of finding the time, space, ing hypothalamus–adrenal–pituitary axis functioning; Blair equipment, and skills needed for videotaping parents and chil- et al., 2008; Bugental, Martorell, & Barraza, 2003; see Polan dren (to which parents must consent), as well as payment for in- & Hofer, 2016), as well as mental representations of the care- tervener time for presession video review and planning. Some giver as helpful and of distress as manageable in a relational interventions involve the delivery of these expensive services context (Bowlby, 1982, 1988/1969). These physiological for relatively long periods of time (e.g., Heinicke et al., 2001). “hidden regulators” and mental representations are thought The lack of attachment interventions scaled to meet broad to contribute to secure attachment (Cassidy, Ehrlich, & Sher- public health needs has led to greater consideration of imple- man, 2013). Moreover, these representations and regulatory mentation issues